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CHEST

An Updated Systematic Review


Kathy Stiller, PhD

Original Research
CRITICAL CARE

Physiotherapy in Intensive Care

Background: Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intubated patients who are mechanically ventilated in the ICU. Methods: The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review. Results: Fifty-ve clinical and 30 nonclinical studies were reviewed. The evidence from randomized controlled trials evaluating the effectiveness of routine multimodality respiratory physiotherapy is conicting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay. Conclusions: Available new evidence, published since 1999, suggests that physiotherapy intervention that comprises early progressive mobilization is benecial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new ndings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists. CHEST 2013; 144(3):825847
Abbreviations: IMT 5 inspiratory muscle training; LOS 5 length of stay; MH 5 manual hyperination; NMES 5 neuromuscular electrical stimulation; RCT 5 randomized controlled/comparative trial; VAP 5 ventilator-associated pneumonia; VH 5 ventilator hyperination

most developed countries, physiotherapy is seen In as an integral component of the multidisciplinary management of patients in ICUs. The role of physiotherapy in the ICU and the treatment techniques used by physiotherapists in the ICU vary consider-

Manuscript received December 5, 2012; revision accepted May 2, 2013. Afliations: From the Physiotherapy Department, Royal Adelaide Hospital, Adelaide, SA, Australia. Funding/Support: The author has reported to CHEST that no funding was received for this study. Correspondence to: Kathy Stiller, PhD, Royal Adelaide Hospital, Physiotherapy Department, North Terrace, Adelaide, SA, Australia, 5000; e-mail: kathy.stiller@health.sa.gov.au 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-2930
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ably between units, depending on factors such as the country in which the ICU is located, local tradition, stafng levels, and expertise. In 2000, Stiller1 published a literature review investigating the effectiveness of physiotherapy for adult, intubated patients on mechanical ventilation in the ICU, covering a broad range of physiotherapy practice. This concluded that there was only limited evidence concerning the effectiveness of physiotherapy in this setting and identied an urgent need for further research to be conducted to justify the role of physiotherapy in the ICU. The review is frequently cited in articles concerning the role of physiotherapy in the ICU. Given that . 10 years have passed since its publication, what new evidence regarding the role of physiotherapy in the ICU has emerged? Does this new evidence conrm the role
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of physiotherapy in the ICU? Does it highlight areas of clinical practice where physiotherapy is most effective? The objective of this systematic review was to update a summary of the evidence concerning the effectiveness of physiotherapy in the ICU. In keeping with Stiller,1 this review only considers the management of adult, intubated patients on mechanical ventilation. Materials and Methods
Search Strategy and Study Selection The PICOS (population, intervention, comparison, outcome and study design) criteria used in this study were deliberately broad to capture all relevant articles, requiring only that the population comprised adult (aged 18 years), intubated, mechanically ventilated patients being cared for in an ICU setting and that a physiotherapy intervention had been evaluated or discussed. No limitations were placed on study outcomes. All relevant clinical articles were included and systematic literature reviews, expert opinion papers, and surveys were also eligible for inclusion. The primary literature search was conducted using the PubMed database for articles published from January 1, 1999, to July 31, 2012, using the following search terms: intensive care AND physiotherapy. Additional searches were undertaken on PubMed using the terms critical care or intensive care AND physical therapy, therapeutic exercise, functional training, exercise, exercise therapy, mobilisation, rehabilitation or ambulation. Secondary searches, using the same time limitations and search terms, were undertaken on MEDLINE, CINAHL, Embase, Cochrane Library, and the Physiotherapy Evidence Database. Titles and abstracts generated by the search strategy were assessed for eligibility and full-text copies of articles deemed to be potentially relevant were retrieved. Duplicate publications were excluded. If relevant articles could not be accessed via the Internet, authors were contacted directly. Given that this was a nonclinical study, institutional review board approval was not sought. Methodological Quality and Analysis The methodological quality of randomized controlled or comparative trials (RCTs) was appraised with reference to the National Health and Medical Research Council Guidelines2 and Consolidated Standards of Reporting Trials (CONSORT) statement.3 All data were extracted by the author. Marked heterogeneity of study design and outcome measures precluded statistical pooling of results for meta-analysis, hence a descriptive summary of the ndings is presented.

did not study the population and/or intervention of interest (Fig 1). Systematic Reviews Twelve systematic literature reviews were identied. Their characteristics, including a summary of their results and conclusions, are shown in Table 1.4-15 In contrast to the current review, which covers a wide range of ICU physiotherapy practices, these reviews focused on specic areas of physiotherapy practice in the ICU, with the most frequent topic being the early mobilization and rehabilitation of patients in the ICU.4-10 Despite only limited data being available, most concluded that early mobilization and rehabilitation are safe and effective in the ICU setting, although further research is required to conrm and extend its role.4-10 Clinical Trials: Study and Patient Characteristics The clinical trials reviewed evaluated a variety of physiotherapy interventions, including multimodality respiratory physiotherapy, mobilization, inspiratory muscle training (IMT), and neuromuscular electrical stimulation (NMES). For the sake of clarity, study ndings are presented according to the intervention evaluated. Multimodality Respiratory Physiotherapy: Eighteen clinical trials were identied that evaluated the effectiveness of multimodality respiratory physiotherapy, with the interventions studied including various combinations of positioning, manual hyperination (MH), ventilator hyperination (VH), chest wall vibrations, and rib-cage compression.16-33 The characteristics and main ndings of these 18 studies are shown in Table 2 (sorted according to methodological quality and sample size). There were ve RCTs,16-20 nine randomized crossover trials,21-29 one systematically allocated controlled trial,30 one historical controlled trial,31 and two observational studies.32,33 Four of the ve RCTs were well designed and involved samples of at least 101 patients.16-19 Study populations comprised patients who were intubated and mechanically ventilated after cardiac surgery,16 mechanically ventilated . 48 h,17,19 or mechanically ventilated with acquired brain injury.18 Patients were prospectively randomly allocated to a control group (usually receiving standard medical/nursing care) or a treatment group that received additional multimodality respiratory physiotherapy (comprising a combination of techniques such as positioning, MH, with or without chest wall vibrations). Frequency of this additional multimodality respiratory physiotherapy was as clinically indicated in two studies,16,17 bid,19 and six times a day.18 Mediumterm clinical outcomes such as duration of intubation, incidence of ventilator-associated pneumonia (VAP),
Original Research

Results Literature Search The initial PubMed literature search identied 849 items published since 1999, with 50 relevant studies (34 clinical, 16 nonclinical) included in the review. An additional 35 relevant studies (21 clinical, 14 nonclinical) were retrieved in a broader PubMed search or from other databases. Thus, in total, 85 new studies (55 clinical, 30 nonclinical) were reviewed. Articles were most often excluded because they
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Figure 1. Flowchart of selection of eligible studies.

and length of stay (LOS) in the ICU and hospital were measured. Two of the four RCTs found no signicant difference between groups for any outcomes,16,18 one found that the median time for 50% of patients to become ventilator-free was signicantly longer in the treatment group,17 and the nal study favored the treatment group, with signicant benets seen in terms of the clinical pulmonary infection score, ventilator weaning and mortality rates.19 The fth RCT was methodologically compromised by a small sample size (n 5 17) that was further compromised by division into three treatment groups.20 The nine randomized crossover trials all had comparatively small sample sizes (n 46) and prospectively evaluated the physiologic effects of individual respiratory physiotherapy interventions.21-29 Six of the randomized crossover trials evaluated MH.21,25-29 Three of these compared MH to VH, when added to a treatment of positioning and suction, with all nding that VH was as effective as MH for outcomes such as sputum clearance and respiratory compliance.21,26,29 Two studies investigated the addition of MH to a treatment of positioning and suction, with both nding that MH was associated with short-term benecial physiologic effects such as improved respiratory compliance.27,28 Hodgson et al25 compared two different circuits for delivering MH, nding that while MH
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with a Mapleson C circuit cleared signicantly more sputum than MH with a Laerdal circuit, this did not have any consequences in terms of oxygenation or respiratory compliance. Two randomized crossover trials evaluated the effect of expiratory rib-cage compression, nding that it did not add to the effectiveness of positioning and suction in terms of oxygenation, respiratory compliance, or sputum clearance.22,23 Finally, Berney et al,24 investigating 20 patients who were mechanically ventilated, found that the addition of a head-down tilt to MH, rather than at side lying, increased the weight of sputum cleared. A prospective, systematically allocated, controlled trial involving 60 patients who were mechanically ventilated was undertaken by Ntoumenopoulos et al.30 While the incidence of VAP was signicantly lower in a group that received multimodality respiratory physiotherapy bid compared with a control group, duration of mechanical ventilation, ICU LOS and mortality were not signicantly different between groups. A large historical controlled trial by Malko et al31 (n 5 501) found that a group that received multimodality respiratory physiotherapy had a signicantly shorter duration of mechanical ventilation and ICU LOS than a historical control group. However, as the treatment group also received mobilization, it is not clear which components of therapy were effective.
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Table 1Characteristics of Systematic Literature Reviews


Topic 15 Studies Reviewed, No. Summary of Results, Authors Conclusions

Study

Mobilization/early rehabilitation Adler and Malone4

Amidei5

Mobilization of critically ill patients with an emphasis on functional outcomes and patient safety. Variables that have been used to evaluate physiologic responses to mobilization. 17

Amidei6 61

Concept of mobilization in the critical care setting.

Choi et al7 10

OConnor and Walsham8 94a

Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation. Worldwide availability of mobilization therapy in ICU and its role.

Thomas9 33a

Rehabilitation of the patient with critical illness. 46a

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Evidence from the limited number of studies that have examined the early mobilization of critically ill patients supports early mobilization as a safe and effective intervention that can have a signicant impact on functional outcomes. Most studies that have investigated the mobilization of critically ill patients evaluated cardiopulmonary function. Future studies evaluating the safety and efcacy of mobilization in this setting should measure multiple physiologic variables, including inammatory biomarkers, and other measures of physiologic function, such as pain, comfort, anxiety, mood, and sleep. Mobilization can be dened as an interdisciplinary, goal-directed therapy aimed at facilitating movement and improving outcomes in critically ill patients. The concept of mobilization needs further denition with respect to factors such as the activities it comprises, their quantity, intensity, duration, and frequency, and interdisciplinary roles. The studies reviewed support the ability of mobility interventions to improve the outcomes of patients receiving prolonged mechanical ventilation, but there is limited evidence on how to best accomplish this goal. There is marked variability between countries in the availability and prescription of mobilization therapy in the ICU setting, with routine mobilization therapy least likely to be available in the United States. The data in support of mobilization therapy for critically ill patients, while of a low level of evidence, are substantial. This justies a paradigm shift in attitudes toward PT and the prevention of critical illness weakness. The evidence available regarding the effectiveness of physical training within the ICU environment is limited to patients with long-term respiratory failure who may not be representative of a general critically ill population. When the rehabilitation of critically ill patients is commenced early during their ICU admission, it leads to a higher rate of PT consultation, and patient-related benets are seen, such as decreased time to achieve activity milestones, improved functional outcomes at ICU and hospital discharge, and reduced direct patient costs. Early rehabilitation of the critically ill patient, led by PTs, has the potential to dramatically inuence recovery and functional outcomes in this vulnerable patient group. 81a Evidence supporting PT Rxs for patients in the ICU is limited due to the lack of long-term studies. While there is strong evidence to support the use of therapist-driven weaning protocols, further studies with larger sample sizes are needed to evaluate the effectiveness of most PT techniques in the ICU.
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Thomas10

Effect of physical rehabilitation commenced immediately on ICU admission compared with delayed rehabilitation.

Respiratory techniques Clini and Ambrosino11

Rationale and effectiveness of specic PT interventions and use of weaning protocols for patients in a respiratory ICU.

Original Research

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Table 1Continued
Topic 19 Studies Reviewed, No. Summary of Results, Authors Conclusions MH results in short-term benecial effects on physiologic endpoints such as respiratory compliance, oxygenation, and airway clearance. However, its effect on broader outcomes, such as duration of mechanical ventilation and ICU LOS, is unknown. MH has been associated with side effects, albeit infrequently. Appropriately powered and methodologically sound studies are needed before it can be recommended for routine use.

Study

Paulus et al12

Benets and risks of MH in critically ill patients.

Other topics Elliott et al13 107a

Observational and functional assessment instruments used to assess patients in the ICU, post-ICU, and posthospitalization. 35

Hanekom et al14

Identify which outcomes should be measured in the adult critical care environment and which outcomes PTs are currently including in research reports.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 34a Studies have used many different outcomes to measure the function of ICU survivors, including muscle strength, functional tests, and health-related quality of life. In general, the sensitivity and validity of these instruments for use with survivors of a critical illness has not yet been established. Research that has investigated the efcacy of PT in ICU has primarily measured physiologic variables or provided descriptions of current practice, without linking these to broader outcomes such as functional status and health-related quality of life. Further work is needed to develop and rene patient-centered and economic measurements that will be sufciently sensitive to be able to measure the effect of PT service provision in ICU. Data concerning the effectiveness of PT and OT for patients in the ICU with traumatic brain injury are very limited, making it impossible to offer clear, evidence-based recommendations. Respiratory PT has not been shown to be effective for the prevention or Rx of VAP. The efcacy of other PT and OT interventions must still be demonstrated.

Hellweg15

Effectiveness of PT and OT for patients in the ICU with traumatic brain injury.

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LOS 5 length of stay; MH 5 manual hyperination; OT 5 occupational therapy; PT 5 physiotherapy or physical therapy; Rx 5 treatment; VAP 5 ventilator-associated pneumonia. aIndicates the number of articles in the reference list (number of studies included in review not specically stated).

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Table 2Characteristics of Studies Evaluating Multimodality Respiratory Physiotherapy


Intervention Outcomes Results Summary of Authors Conclusions

Study

Participants, No., Type

Prospective, randomized, controlled/comparative trials 210, intubated, Patman et al16 mechanically ventilated, post-cardiac surgery. Templeton and Palazzo17 180, intubated, mechanically ventilated . 48 h. Duration of intubation, ICU and hospital LOS, incidence of postoperative pulmonary complications. Time to become ventilator-free, Median time for 50% to become ICU and hospital mortality, ventilator-free signicantly longer ICU LOS. in Rx group. No signicant difference between groups for any other outcome. Incidence of VAP, duration of mechanical ventilation, ICU and hospital LOS, CPIS scores, Pao2/Fio2. No signicant difference between groups for any outcome. No signicant difference between groups for any outcome.

For routine, uncomplicated cardiac surgery subjects, the provision of PT interventions during the postoperative intubation period did not improve outcomes. Standard care is at least as effective as chest PT in patients requiring mechanical ventilation . 48 h.

Patman et al18

144, intubated, mechanically ventilated . 24 h, acquired brain injury. CPIS score, mortality, weaning success, duration of intubation, ICU LOS.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Control: standard medical/nursing care. Rx: as for control plus PT as indicated, including positioning, MH, suction. Control: standard medical/nursing care. Rx: as for control plus respiratory PT as indicated, including positioning, MH, chest wall vibrations, suction. Control: standard medical/nursing care. Rx: as for control plus respiratory PT, including positioning, MH, suction, 6 times/d. Control: MH and suction bid. Rx: as for control plus positioning, chest wall vibrations. A regular respiratory PT regimen in addition to routine medical/nursing care did not signicantly decrease the incidence of VAP, duration of mechanical ventilation or ICU LOS in adults with acquired brain injury. Multimodality respiratory PT bid decreased CPIS scores, suggesting a decrease in VAP and mortality rates. Group 1: supine 30 head-up, 3-min preoxygenation (Fio2 5 1), suction. Group 2: as for group 1, then positioned (L and R at side lying), suction. Group 3: as for group 2, plus MH. Pao2, Paco2, dynamic respiratory compliance, peak airway pressure, HR, BP, Svo2 before and 10-, 30-, and 60-min post-Rx. Reduction in CPIS score signicantly greater in Rx group. Weaning success signicantly higher in Rx group. Mortality signicantly lower in Rx group. No signicant difference between groups for duration of intubation or ICU LOS. Signicant changes observed in Paco2 and compliance over time for all three groups (Paco2 increased, compliance decreased 10-min post-Rx). Pao2/Fio2 and Svo2 did not signicantly change in any group. Svo2 was signicantly lower in group 2. HR and BP showed signicant, but not clinically important, changes over time. Disconnection of patients with ALI from mechanical ventilation for PT Rx can result in signicant derecruitment of the lungs and altered physiology. The use of MH does not appear to override the loss of PEEP and the derecruitment effects.
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Pattanshetty and Gaude19 101, intubated, mechanically ventilated . 48 h.

Barker and Adams20

17, intubated, mechanically ventilated, ALI.

Original Research

Table 2Continued

Study

Participants, No., Type Intervention Outcomes Results

Summary of Authors Conclusions

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Prospective, randomized, crossover trials Dennis et al21 Control: positioning, VH, chest-wall vibrations, suction. Rx: as for control except MH not VH. Control: positioning, suction. Rx: as for control plus 5-min expiratory rib-cage compression presuction. No signicant difference between Rxs for any outcome. No signicant difference seen from pre- to post-Rx for any outcome. Signicantly higher airway pressure with MH than VH. No signicant difference between Rxs for other outcomes.

Unoki et al22

Sputum weight, Vt, HR, MAP, dynamic respiratory compliance, airway pressure, Pao2/Fio2 before, immediately and 30-min post-Rx. Pao2/Fio2, Paco2, dynamic respiratory compliance, sputum weight before and 25-min post-Rx.

VH was as safe and effective during respiratory PT Rx as MH, when applied with the same parameters and precautions. VH has potential advantages over MH, the biggest being that no ventilator circuit disconnection is required. The routine use of rib-cage compression is not recommended in a general population of mechanically ventilated patients.

Genc et al23

46, intubated, mechanically ventilated, atelectasis or consolidation on CXR. 31, intubated, likely to require mechanical ventilation . 48 h. 22, intubated, mechanically ventilated.

The routine use of rib-cage compression during MH is not recommended in a general population of mechanically ventilated patients. The head-down tilt position should be considered when the primary aim of Rx is sputum removal for intubated, mechanically ventilated patients.

Berney et al24

20, intubated, mechanically ventilated.

Control: positioning, 5-min MH, suction. Rx: as for control plus expiratory rib-cage compression during MH. Control: side lying at, MH, suction. Rx: as for control but side lying in head-down tilt.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Pao2/Fio2, Paco2, static respiratory compliance, sputum weight, Vt, HR, MAP before and 5- and 20-min post-Rx. Sputum weight, PEFR during MH, static respiratory compliance before and immediately post-Rx. Rx 1: positioning, MH with Sputum weight, static Mapleson C circuit, suction. respiratory compliance, Vt, Pao2/Fio2, Paco2 before, Rx 2: as for Rx 1 except MH 30-, and 60-min post-Rx. with Laerdal circuit. Rx 1: positioning, MH, Sputum weight, static suction. respiratory compliance before, immediately Rx 2: as for Rx 1 except VH. and 30-min post-Rx. Control: positioning, suction. Rx: as for control plus MH. Static respiratory compliance, Pao2/Fio2, Paco2, sputum weight, HR, MAP before, immediately and 20-min post-Rx. No signicant difference between Rxs for any outcome. Compliance and Vt signicantly increased from pre- to post-Rx. No signicant change in other outcomes. Signicantly more sputum and higher PEFR during Rx with head-down tilt. Compliance signicantly improved over time, no signicant difference between Rxs. MH with Mapleson C circuit cleared signicantly more sputum. No signicant difference between Rxs for other outcomes. No signicant difference between Rxs in sputum weight or compliance. Compliance signicantly improved after both Rxs. Signicantly greater increase in compliance and sputum weight for MH Rx. Increase in compliance seen immediately and 20-min post-Rx. No signicant difference between Rxs for other outcomes. More secretions were cleared using the Mapleson C compared with the Laerdal circuit; however, this had no consequence in terms of oxygenation. VH was as effective as MH in sputum clearance and improving respiratory compliance. Respiratory compliance and sputum clearance were improved by the addition of MH to a Rx of positioning and suctioning without compromise to cardiovascular stability or gas exchange.
(Continued)

Hodgson et al25

20, intubated, mechanically ventilated.

Berney and Denehy26

20, intubated, mechanically ventilated.

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Hodgson et al27

18, intubated, mechanically ventilated, lung collapse and/or consolidation on CXR, Pao2/Fio2 , 350.

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Table 2Continued

Study Control: supine, suction. Rx: as for control plus MH. Static respiratory compliance, airway resistance before, immediately and 30-min post-Rx. Signicantly greater increase in compliance for MH Rx. Signicant decrease in airway resistance 30-min post-MH Rx but not control Rx.

Participants, No., Type Intervention Outcomes Results

Summary of Authors Conclusions

Choi and Jones28

15, intubated, mechanically ventilated, VAP.

Savian et al29

14, intubated, mechanically ventilated.

Rx 1: positioning, MH, suction. Rx 2: as for Rx 1 except VH.

PEFR, Vt, Pao2/Fio2, static respiratory compliance, HR, MAP, sputum weight, co2 before, immediately and 30-min post-Rx.

Signicantly higher PEFR with MH. Signicantly higher Vt with VH. co2 signicantly different between Rxs (upward trend MH, downward trend VH). No signicant difference between Rxs for other outcomes.

Suction alone did not cause deterioration in compliance and airway resistance and can probably be used safely in patients with VAP. The addition of MH improved respiratory mechanics compared with suction alone. VH promoted greater improvements in respiratory mechanics with less metabolic disturbance than MH. Other variables such as sputum production, hemodynamics and oxygenation were affected similarly by both techniques.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Control: side lying, suction as required. Rx: positioning, expiratory chest wall vibrations, suction, bid. Incidence of VAP, CPIS score, Signicantly lower incidence of VAP duration of mechanical and CPIS score in Rx group. No ventilation, ICU LOS, signicant difference between ICU and 28-d mortality. groups for other outcomes. Respiratory PT was independently associated with a reduction in VAP. Control (historical): standard nursing care. Rx: positioning, percussion, vibration, coughing, deep breathing, suction, bed exercises, mobilization (not described), bid, 5 d/wk. Duration of mechanical ventilation, ICU LOS. Signicantly shorter duration of mechanical ventilation and ICU LOS in Rx group. PT can reduce the period of Rx required in ICU.
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Prospective, systematically allocated, controlled trial Ntoumenopoulos et al30 60, intubated, mechanically ventilated 48 h.

Prospective, historical controlled trial Malko et al31

510, intubated, mechanically ventilated.

Original Research

ALI 5 acute lung injury; CPIS 5 clinical pulmonary infection score; CXR 5 chest radiograph; HR 5 heart rate; L 5 left; MAP 5 mean arterial BP; PEEP 5 positive end expiratory pressure; PEFR 5 peak expiratory ow rate; R 5 right; Svo2 5 mixed venous oxygen saturation; co2 5 CO2 output; VH 5 ventilator hyperination; Vt 5 tidal volume. See Table 1 legend for expansion of other abbreviations.

The results did not support the use of lateral positioning to improve oxygenation in ventilated patients without lung pathology or with pulmonary inltrates.

Manual hyperventilation causes higher ination pressures and smaller Vts as the lung score increases, suggesting an increased potential for barotrauma or volutrauma in susceptible lungs.

Summary of Authors Conclusions

From the two prospective observational studies, Thomas et al32 found that lateral positioning had no signicant effect on oxygenation of 34 patients on mechanical ventilation and Clarke et al,33 studying 25 patients on mechanical ventilation, reported that manual hyperventilation can result in higher ination pressures in patients with susceptible lungs. Mobilization: For the purposes of this review, the definition of mobilization provided by Stiller1 has been used, whereby mobilization is a broad term that encompasses active limb exercises, actively moving or turning in bed, sitting on the edge of the bed, sitting out of bed in a chair (via mechanical lifting machines, slide board, or standing transfer), standing, and walking. Twenty-six clinical trials were identied that evaluated the use of mobilization interventions.34-59 Table 3 summarizes their characteristics. There were three RCTs,34-36 ve nonrandomized controlled trials,37-41 one historical controlled study,42 and 17 observational studies.43-59 The largest prospective RCT, by Schweickert et al,34 involved 104 patients who had been mechanically ventilated for , 72 h and were likely to require ventilation for a further 24 h. The patients were randomly allocated to receive daily sedative interruption followed by therapy that concentrated on mobilization activities (eg, range of motion exercises, functional tasks, sit/stand/walk) or daily sedative interruption and standard medical/nursing care. Compared with the control group, the treatment group demonstrated a signicantly shorter duration of delirium and mechanical ventilation, and signicantly more patients in the treatment group achieved an independent functional status at hospital discharge. The second prospective RCT, involving 90 patients whose ICU LOS was anticipated as being . 7 days, investigated the effectiveness of adding cycling exercise using a bedside cycle ergometer to a standard physiotherapy mobilization regimen (ie, limb exercises, walk).35 While no signicant differences were found between groups at ICU discharge, the treatment group achieved signicantly higher distances in the 6-min walk test than the control group at hospital discharge and their quadriceps strength improved signicantly between ICU and hospital discharge. The third RCT, by Chang et al,36 prospectively investigated the effect of sitting out of bed (for at least 30 min, most often on a daily basis) on the respiratory muscle strength of 34 patients over a 6-day study period. The patients in the control group were positioned supine or semirecumbent in bed. No signicant differences were seen between groups. Two of the ve nonrandomized controlled studies prospectively allocated patients to a control group (standard medical/nursing care) or a treatment group (progressive
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Participants, No., Type

Prospective, observational studies 34, intubated, Thomas et al32 mechanically ventilated with or without pulmonary inltrates on CXR. Clarke et al33 25, sedated, intubated, mechanically ventilated.

Study

90 side lying.

Manual hyperventilation with Mapleson C circuit.

Intervention

Pao2 /Fio2, Paco2, Vt, No signicant change in Pao2/Fio2, dynamic respiratory Paco2, MAP, HR. compliance, airway pressure, Compliance and Vt signicantly MAP, HR, cardiac index, decreased during positioning, cardiac adverse events before, index signicantly increased 30-min during, and 30- and post-Rx. 21% incidence of adverse 120-min post-Rx. events (minor, transient). Vt, peak airway pressure, Signicant negative correlation between Pao2, Paco2 before, average Vt and lung injury score. during, and immediately Signicant positive correlation between post-Rx. average peak airway pressure and lung injury score. Pao2 signicantly improved from pre- to immediately post-Rx. No signicant change in Paco2.

Table 2Continued

Outcomes

Results

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Table 3Characteristics of Studies Evaluating Mobilization


Intervention Outcomes Results Summary of Authors Conclusions

Study

Participants, No., Type

Prospective, randomized, controlled/comparative trials 104, intubated, Schweickert et al34 mechanically ventilated , 72 h, likely to continue 24 h. Return to independent functional status at hospital DC, duration of delirium and mechanical ventilation, ventilator-free days, ICU and hospital LOS, adverse events.

Sedation interruption and PT/OT in the earliest days of critical illness was safe and well tolerated, resulted in better functional outcomes at hospital DC, shorter duration of delirium, and more ventilator-free days. When instituted early in ICU survivors with a prolonged stay, exercise training may enhance recovery of functional exercise capacity, functional status, and quadriceps force at hospital DC. 6 d of chair sitting was ineffective at improving respiratory muscle function in mechanically ventilated patients in the ICU.

Burtin et al35 6MWD at hospital DC, quadriceps force, functional status (sit-to-stand [BBS] and physical functioning [SF-36]) at ICU and hospital DC, adverse events.

90, critically ill, anticipated ICU LOS . 7 d postrecruitment.

Control: daily sedative interruption and standard care (included PT and OT per primary care team). Rx: daily sedative interruption for PT and OT (eg, ROM exercises, bed mobility, functional and ADL tasks, sit/stand/walk). Control: standard PT mobilization (limb exercises, walk), 5 d/wk. Rx: as for control plus cycling exercise (bedside cycle ergometer), 20 min, 5 d/wk.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Control: positioned supine to semi-recumbent, no PT. Rx: sit in chair, 30-120 min, at least 3 d/wk. Rapid shallow breathing index, Vt, respiratory muscle strength before and 30-min postintervention over 6-d trial period. Return to independent functional status at hospital DC occurred in signicantly more Rx group patients. Duration of delirium and mechanical ventilation signicantly shorter in Rx group. Ventilator-free days, and ICU and hospital LOS not signicantly different between groups. Serious adverse events: 0.2%. 6MWD and SF-36 subscore signicantly higher in Rx group at hospital DC. Quadriceps force improved signicantly more between ICU and hospital DC in Rx group. Ability to stand independently (BBS 2) not signicantly different between groups. Serious adverse events: 0%. No signicant differences between groups for any outcome over 6-d trial period. Control: standard medical/nursing care. Rx: progressive mobilization (eg, ROM exercises, functional tasks, sit/stand/walk) from a mobility team, 7 d/wk. Proportion receiving ICU PT, days until rst out of bed, ventilator days, ICU and hospital LOS, adverse events. ICU PT provided to signicantly more patients in Rx group. Rx group rst out of bed signicantly earlier. ICU and hospital LOS signicantly shorter in Rx group. Ventilator days not signicantly different between groups. Serious adverse events: 0%. Implementation of an early mobility protocol by a mobility team resulted in more PT sessions and was associated with a shorter LOS for hospital survivors.
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Chang et al36

34, mechanically ventilated 72 h, able to transfer to chair with two nurses.

Prospective, nonrandomized, controlled trials Morris et al37

330, intubated, mechanically ventilated, acute respiratory failure.

Original Research

Table 3Continued
Intervention Rapid shallow breathing index, BI, weaning success. Timing not clear. Not stated. Outcomes Results Summary of Authors Conclusions

Study

Participants, No., Type

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Yang et al38

126, mechanically ventilated . 14 d.

Winkelman et al39

75, mechanically ventilated . 48 h, likely to continue 24 h.

Control: routine passive joint exercises by nurses 5-10 min, bid. Rx: breathing training, progressive mobilization (eg, passive/active ROM exercises, sit/stand/walk), 30 min, daily, 5 times/wk. Control phase: standard medical/nursing care. Rx phase: progressive mobilization (per Morris et al37), 20 min, daily, 2-7 d. Inammatory biomarkers, HR, RR, systolic BP, Spo2, adverse events over 7-d trial period. Duration of mechanical ventilation, ICU LOS.

The results should encourage clinicians to add mobility protocols to the care of patients in the ICU.

Needham et al40

57, mechanically ventilated . 4 d.

Control phase: standard medical/nursing care. Rx phase: reduced sedation, early progressive mobilization (eg, sit/stand/walk).

Prevalence of deep sedation and delirium, functional mobility, ICU and hospital LOS, adverse events.

Reducing deep sedation and increasing early mobilization resulted in substantial improvements in ICU delirium and functional mobility, with a decrease in ICU and hospital LOS. A 6-wk physical training program may improve limb muscle strength and ventilator-free time and improve functional outcomes in patients requiring prolonged mechanical ventilation.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Control: standard medical/nursing care including promotion of mobilization (eg, exercises, walk). Rx: progressive mobilization (eg, strengthening and ROM exercises, sit/stand/walk), 5 times/wk for 6 wk. Respiratory muscle strength, upper and lower limb strength, BI, FIM, ventilator-free time at 3 and 6 wk. Rapid shallow breathing index did not signicantly change. BI signicantly improved over time in Rx group (not clear what happened to control). Weaning success rate higher in Rx group (signicance not stated). Daily exercise linked to increased IL-10. HR, RR, systolic BP, Spo2 not signicantly different between control and Rx phases. Serious adverse events: , 5%. Duration of ventilation not signicantly different between phases. ICU LOS signicantly shorter during Rx phase. Prevalence of deep sedation and delirium signicantly lower during Rx phase. Functional mobility signicantly better during Rx phase. Signicantly shorter ICU and hospital LOS during Rx phase compared with prior year. Serious adverse events: 0%. Respiratory muscle and limb strength signicantly increased at 3 and 6 wk in Rx group but not control group. BI and FIM scores signicantly higher in Rx group than control group at 3 and 6 wk. Ventilator-free time increased signicantly in Rx group but not control group at 6 wk. Control: historical control. Rx: progressive mobilization (eg, ROM exercises, functional tasks, sit/stand/walk). Ventilator days, ventilator-free days, ICU and hospital mortality, ICU and hospital LOS, days to standing and ambulating. No signicant differences between groups for any outcomes. An early mobility program improved ICU team focus on the process of early mobility, but no signicant differences were seen in quantitative outcomes.
(Continued)

Chiang et al41

32, mechanically ventilated . 14 d.

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Prospective, historical controlled trial Bassett et al42

260, not stated.

835

836

Table 3Continued
Intervention Outcomes Results Summary of Authors Conclusions

Study

Participants, No., Type

Prospective, observational studies Leditschke et al43 Usual practice. Frequency of mobilization (sit/stand/walk), adverse events, barriers to mobilization. Frequency of ambulation.

106, all patients in ICU.

Critically ill patients can be safely mobilized.

Thomsen et al44 Early progressive mobilization (eg, sit/walk) following transfer.

Patients were mobilized on 54% of days audited. Adverse events: 1%. Avoidable barriers included location of vascular access lines, scheduling of mobilization, sedation. Probability of ambulation signicantly increased after transfer to the respiratory ICU. After 2 d, number of patients ambulating increased threefold compared with pretransfer. Total of 1,449 early mobilization activities. Adverse events: , 1%. Hospital mortality: 87%. Weaning success: 74%. BADL score improved. Adverse events: 0%.

The ICU environment may contribute to the unnecessary immobilization of patients with acute respiratory failure.

Bailey et al45

Early progressive mobilization (eg, sit/walk). Mortality, weaning success, BADL score at baseline and ICU DC, adverse events. Level of mobilization achieved, adverse events.

Feasibility, adverse events.

Clini et al46

104, transferred from general ICU to a specic respiratory ICU, mechanically ventilated . 4 d, respiratory failure. 103, mechanically ventilated . 4 d, respiratory failure. 77, tracheostomized, difcult to wean.

Early mobilization is feasible and safe in respiratory failure patients. Early rehabilitation contributes to BADL recovery in difcult-to-wean patients.

Garzon-Serrano et al47

Early rehabilitation including progressive mobilization (eg, limb exercises, sit/stand/walk), weaning protocol, nutritional support. 63, all patients in ICU. Mobilization (eg, limb exercises, bed mobility, sit/stand/walk) by nursing or PT staff. Mobilization (eg, limb exercises, balance, functional activities, sit/stand/walk). HR, BP, Spo2 before and postsession, ROM, muscle strength, functional outcomes, adverse events.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Routine involvement of PTs in directing mobilization Rx may promote early mobilization of critically ill patients. Rehabilitation therapy appeared safe without signicant physiologic changes or adverse effects, but was only provided infrequently. Mobilization (eg, sit/stand/walk). Usual care, including sitting. HR, BP, Spo2 before, during and immediately postsession, adverse events. Frequency of sitting out of bed. PTs mobilized patients to a signicantly higher level of mobility than nursing staff. Adverse events: 0%. HR, BP, Spo2: minimal changes during sessions. Lower-limb joint contractures frequent, did not improve during hospitalization. Limb weakness common, improved during hospitalization. Adverse events: 0%. HR and BP increased signicantly during sessions. No signicant change in Spo2. Adverse events: 4% (minor, transient). 63% sat out of bed on a median of two occasions. Acutely ill patients in the ICU can be safely mobilized without major deterioration in their clinical status. Despite a culture of early mobilization, some patients were considered too unwell for it to occur.
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Zanni et al48

32, mechanically ventilated . 4 d.

Stiller et al49

31, any patient in ICU being mobilized by PTs.

Bahadur et al50

30, tracheostomized, mechanically ventilated.

Original Research

Table 3Continued
Intervention Early progressive mobilization (eg, sit/tilt table/walk). Feasibility, HR, RR, MAP, Spo2 before and postsession, adverse events. Outcomes Results Summary of Authors Conclusions Early mobilization is feasible and safe for patients in ICU for . 7 d.

Study

Participants, No., Type

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Bourdin et al51

20, mechanically ventilated 2 d, ICU stay 7 d.

Nordon-Craft et al52

Adverse events, feasibility, muscle strength, functional outcomes. o2, CIX, O2ER before and during intervention.

Early mobilization and PT were safe and feasible for patients with ICU acquired weakness. Simple maneuvers like passive limb movements can inuence the hemodynamic status of patients in ICU. Standing on a tilt table produced a transient increase in ventilation in critically ill patients. Changes in Vt, RR, and e during mobilization were largely due to positional change from supine to standing.

Norrenberg et al53

19, mechanically ventilated 7 d, ICU acquired weakness. 16, patients in ICU.

Progressive mobilization (eg, limb exercises, sit/stand/walk), 30 min, 5 d/wk. Passive limb movements.

Chang et al54 Standing on a tilt table (70 from horizontal), 5 min. e, Vt, RR, Pao2, Paco2 before, during, immediately and 20-min postintervention. Rib cage and abdomen displacement, Vt, RR, e, HR, BP, Spo2, Pao2, Paco2 before, during, and 20-min postintervention.

15, intubated, mechanically ventilated . 5 d.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Early mobilization (eg, sit/stand/walk) while spontaneously breathing on Fio2 5 1.0. Progressive mobilization (eg, limb exercises, sit/stand/walk). Passive ROM exercises upper and lower limbs. Chair sitting signicantly decreased HR and RR. HR and RR signicantly increased with tilting-up and walking. Spo2 signicantly decreased with walking. Adverse events: 3% (minor). Adverse events: 0%. 170 sessions provided. Patients DC home had higher strength and functional scores. o2 signicantly increased during intervention: achieved by increase in O2ER in patients with cardiac dysfunction, by increase in CIX in patients without cardiac dysfunction. e, RR, and Vt signicantly increased during and immediately post-tilt, not signicant by 20 min post-tilt. Pao2 and Paco2: no signicant change. Standing signicantly increased rib cage displacement, Vt, RR, and e. No further signicant changes seen with walking. BP and HR signicantly increased when the patients sat on edge of bed. Pao2 and Paco2: no signicant change. The test was easy to perform, responsive and reliable. Adverse events: 0%. Responsiveness and reliability of the physical function ICU test, adverse events. ICP, CPP, CBFV, PI, BP, and HR before, during, and 10 min postintervention. ICP signicantly decreased postintervention. No signicant change in other outcomes. This test may be used to prescribe and evaluate exercise for weak, debilitated patients in ICU. Passive ROM exercises can be used safely in critically ill neurosurgical patients in ICU.
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Zaropoulos et al55

15, intubated, mechanically ventilated, elective major abdominal surgery.

Skinner et al56

12, tracheostomized, mechanically ventilated.

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Thelandersson et al57

12, mechanically ventilated, unable to actively move, severe head injury.

837

6MWD 5 6-min walk distance; ADL 5 activities of daily living; BADL 5 basic activities of daily living; BBS 5 Berg Balance Scale; BI 5 Barthel Index; CBFV 5 cerebral blood ow velocity; CIX 5 cardiac index; CPP 5 cerebral perfusion pressure; DC 5 discharge; FIM 5 functional independence measure; ICP 5 intracranial pressure; O2ER 5 oxygen extraction ratio; PI 5 pulsatility index; ROM 5 range of motion; RR 5 respiratory rate; SF-36 5 Medical Outcomes Study 36-Item Short Form Health Survey; Spo2 5 percutaneous oxygen saturation; e 5 minute ventilation; o2 5 oxygen consumption. See Table 1 and 2 legends for expansion of other abbreviations.

mobilization [eg, limb exercises, sit/stand/walk]).37,41 Despite marked differences in sample size (n 5 33037; n 5 3241), both demonstrated advantages for the treatment group, including signicantly better functional ability, which translated into benets such as a significantly shorter ICU and hospital LOS. Two nonrandomized controlled studies prospectively compared a control phase, where patients received standard medical/nursing care, to a treatment phase following the introduction of a progressive mobilization program.39,40 Needham et al40 demonstrated benets following implementation of the mobilization program (which included reduced sedation), including signicantly better functional mobility in the ICU and significantly shorter ICU and hospital LOS. Similarly, Winkelman et al39 found that the ICU LOS was significantly shorter after implementation of a progressive mobilization program, although no signicant difference was found for duration of mechanical ventilation. Yang et al38 found that progressive mobilization enhanced the success rate of ventilator weaning. Bassett et al42 compared outcomes between a historical controlled group, where data were collated retrospectively, and a treatment group after the implementation of an early mobilization program across 13 ICUs. While details are scarce, no signicant differences were seen between the two groups for outcomes such as the length of mechanical ventilation, and ICU and hospital LOS. The 17 observational studies recorded outcomes regarding the feasibility, safety, and physiologic effects of mobilization on patients in the ICU.43-59 Overall, mobilization activities were found to be feasible and safe, although associated at times with short-term changes in physiologic parameters, with the frequency of serious adverse events 1%. Garzon-Serrano et al47 prospectively compared the level of mobility achieved for 63 patients in the ICU according to whether mobilization was performed by nursing or physical therapy staff, nding that physical therapists mobilized patients to a signicantly higher level than nursing staff. Barriers to the mobilization of patients in the ICU that were identied included the ICU culture,44 sedation,48 limited rehabilitation stafng,48 and patients being medically unt.50 Skinner et al56 developed a clinical exercise outcome measure for use in the ICU, namely, the physical function ICU test (PFIT), nding it easy to use, responsive, and reliable in a study of 12 patients in the ICU. Inspiratory Muscle Training: Five clinical trials were found that evaluated the effectiveness of IMT in the ICU.60-64 These studies are summarized in Table 4. There were two RCTs,60,61 two case series,62,63 and one single case report.64
Original Research

Summary of Authors Conclusions

Table 3Continued

Passive ROM exercises to one leg.

12, mechanically ventilated, unable to actively move, severe head injury. Thelandersson et al58

Participants, No., Type

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Study

Hashim et al59

1, mechanically ventilated, fractured ribs.

Standing on a tilt table, daily.

Intervention

Blood ow velocity and resistance index of common femoral artery, HR, BP before and 10-min postintervention. Descriptive data.

Outcomes

No signicant change in any outcome.

Tilt table prompted faster standing than other approaches and improved respiratory function.

Results

Passive ROM does not alter blood ow velocity or resistance index in the common femoral artery in comatose and/or sedated critically ill patients. Early mobilization using a tilt table may enhance respiratory function and shorten recovery.

Cader et al,60 in a well-designed prospective RCT involving 41 elderly patients who were mechanically ventilated for . 48 h due to type 1 respiratory failure, found that daily progressive IMT using a threshold training device was associated with signicant benets (eg, shorter weaning time) compared with a control group. In contrast, the prospective RCT by Caruso et al,61 whose study sample comprised 25 patients likely to require mechanical ventilation . 72 h, found that IMT using the trigger sensitivity on the ventilator did not have signicant benets in terms of weaning duration or rate of reintubation. Threshold IMT was found to be effective in terms of weaning ventilator-dependent patients in the case series by Sprague and Hopkins63 involving six patients, and a single case study by Bissett and Leditschke.64 Bissett et al,62 in another case series, evaluated the safety of IMT, with no deleterious effects on physiologic parameters or clinically important adverse effects recorded. Neuromuscular Electrical Stimulation: Three clinical studies, summarized in Table 4, were identied that evaluated the effectiveness of NMES.65-67 There were two prospective, stratied RCTs65,66 and one within-subject RCT.67 The RCT by Routsi et al65 involved 52 critically ill patients, stratied according to age and sex, and evaluated the effect of daily NMES to the quadriceps and peroneous longus muscles. They demonstrated a signicantly lower incidence of critical-illness polyneuromyopathy and reduced weaning time in the treatment group. The stratied RCT by Gruther et al66 allocated 33 patients to a daily session of NMES to the quadriceps muscle or a sham treatment, with the sample stratied according to ICU LOS. While no signicant difference was seen between the treatment and sham groups for short-stay patients (, 7 days), longer-term patients (. 14 days) who received NMES had a significant increase in muscle thickness at 4 weeks, whereas the sham group had no signicant change in muscle thickness. The within-subject RCT by Poulsen et al,67 involving eight male patients in the ICU with septic shock, found no signicant difference in quadriceps muscle volume between patients control and treatment sides after 7 days. Other Clinical Trials: Three other clinical trials that investigated physiotherapy interventions in the ICU are summarized in Table 4.68-70 Zeppos et al68 documented a low incidence of adverse physiologic effects associated with all physiotherapy interventions in the ICU; De Freitas69 found that patients who received physiotherapy were predominantly male, elderly, nonsurgical, and with high disease severity and mortality; and Clavet et al70 reported that patients
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with joint contractures in the ICU had a signicantly longer ICU LOS and lower ambulatory level at the time of hospital discharge than those without joint contractures. Nonclinical Studies: Study and Sample Characteristics Expert Opinion: Three articles, summarized in Table 5, provided expert opinions regarding the role of physiotherapy in the ICU.71-73 Gosselink et al71 summarized the ndings of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on the effectiveness of physiotherapy for acute and chronic critically ill patients. Despite noting a lack of high-level evidence, they identied the following evidence-based targets for physiotherapy: deconditioning, muscle weakness, joint stiffness, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. The two studies by Hanekom et al72,73 used a Delphi process to develop evidence-based clinical management algorithms for the prevention, identication, and management of pulmonary dysfunction in intubated patients in the ICU and for the early physical activity and mobilization of critically ill patients. Surveys: A total of 15 surveys (Table 5) were identied that evaluated physiotherapy interventions in the ICU.74-88 Sample sizes ranged from 3288 to 482;74 most samples comprised physiotherapists alone,74-76,78-81,84-86,88 two included physiotherapists and nursing staff,82,83 one study included ICU directors and physiotherapists,77 and the last included patients in the ICU.87 All studies used purpose-designed surveys. Topics surveyed were general physiotherapy service provision,74,79,80,82,85 use of passive movements,75,86 rehabilitation and exercise prescription,78 positioning,83 VH,76,84 MH,88 use of tilt tables,81 ICU directors perceptions of their physiotherapy service,77 and patient satisfaction with the ICU physiotherapy service.87 The ndings of each study are summarized in Table 5.

Discussion This systematic review updates a summary of the research evidence concerning the effectiveness of physiotherapy in the ICU published in 2000. A total of 85 new studies (55 clinical and 30 nonclinical) were reviewed. The most striking change in the evidence base since the review published by Stiller in 20001 has been the advent and growth of research, particularly in the last 5 years, evaluating the use of early progressive mobilization. In contrast to 2000, when no studies were
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840 Participants, No., Type Intervention Outcomes Results Summary of Authors Conclusions 41, intubated, mechanically ventilated . 48 h, . 70 y old, type 1 respiratory failure. 25, likely to require mechanical ventilation . 72 h. Control: usual care. Rx: IMT (threshold device, progressive resistance), 5 min bid, 7 d/wk. In intubated older people, IMT improves MIP and the Index of Tobin, with a reduced weaning time in some patients. IMT from the beginning of mechanical ventilation did not shorten weaning duration or decrease reintubation rate. MIP, Index of Tobin (RR/Vt during a 1-min spontaneous breathing trial) before and postweaning, weaning time. MIP daily until weaned, weaning duration, reintubation rate. MIP increased signicantly more in Rx group. Index of Tobin worsened in both groups, but signicantly less so in Rx group. Weaning time signicantly shorter in Rx group. No signicant difference between groups for any outcome. 10, tracheostomized, ventilator dependent. 6, tracheostomized, ventilator dependent. HR, MAP, Spo2, RR: no signicant change. Adverse events: 0%. All patients were weaned from the ventilator after initiation of IMT. Mean training pressures and MIP increased over time. Weaned off mechanical ventilation after initiation of IMT. HR, MAP, Spo2, RR before and post-sessions until weaned, adverse events. Weaning success, training pressures, MIP. Threshold IMT can be delivered safely in selected ventilator-dependent patients. IMT may promote weaning in patients who are ventilator-dependent. 1, tracheostomized, ventilator dependent. Weaning success. IMT should be considered as a therapeutic strategy for ventilator-dependent patients.

Table 4Characteristics of Studies Evaluating Inspiratory Muscle Training, Neuromuscular Electrical Stimulation, and Other Interventions

Study

Study Design

Inspiratory muscle training Cader et al60

Prospective, randomized, controlled trial.

Caruso et al61

Prospective, randomized, controlled trial.

Bissett et al62

Case series

Sprague and Hopkins63

Case series.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Control: usual care. Rx: IMT (inspiratory trigger sensitivity on ventilator, progressive resistance), up to 30 min per session bid. IMT (threshold device, progressive resistance), daily, 5-6 d/wk. IMT (threshold device, progressive resistance), 30-50 min per session, daily, 6-7 d/wk. IMT (threshold device, progressive resistance), up to 30 min per session, daily, 7 d/wk. 52, mechanically ventilated, APACHE II score 13. Stratied according to age and sex. Control: no intervention. Rx: NMES to quadriceps and peroneous longus bilaterally, 55 min daily. MRC muscle strength, frequency of critical illness polyneuromyopathy, weaning period, duration of mechanical ventilation, ICU LOS. MRC score signicantly higher in Rx group. Incidence of polyneuromyopathy signicantly lower in Rx group. Weaning period signicantly shorter in Rx group. No signicant difference between groups for other outcomes. Daily NMES can prevent critical illness polyneuromyopathy in critically ill patients and can shorten the duration of weaning.
(Continued)

Bissett and Leditschke64 Single case study.

Neuromuscular electrical stimulation Routsi et al65

Prospective, stratied, randomized, controlled trial.

Original Research

Table 4Continued
Participants, No., Type 33, stratied according to ICU LOS: acute subgroup: ICU LOS , 7 d; long-term subgroup: ICU LOS . 14 d. Control: sham stimulation. Rx: NMES to quadriceps, daily, 5 d/wk for 4 wk. Quadriceps muscle layer thickness (ultrasonography) at baseline and 4 wk. Intervention Outcomes Results Summary of Authors Conclusions NMES could be an effective adjunct in ICU to reverse muscle wasting in long-term patients.

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Study

Study Design

Gruther et al66

Prospective, stratied, randomized, controlled trial.

Poulsen et al67 8, mechanically ventilated, septic shock, predicted ICU LOS 7 d. Control side: no intervention. Rx side: NMES to quadriceps, 60 min, daily for 7 d. Any PT intervention. Adverse events. Quadriceps muscle volume (CT image) at days 1 and 7.

Within-subject, randomized, controlled trial.

Acute subgroup: muscle thickness signicantly decreased over time in both groups, no signicant difference between groups. Long-term subgroup: muscle thickness signicantly increased over time in Rx group but not control group, thickness signicantly greater in Rx group at 4 wk. Muscle volume signicantly decreased over time. No signicant difference between groups.

Loss of muscle mass in patients with septic shock was unaffected by NMES.

Other interventions Zeppos et al68

12,281 interventions provided. Adverse events: 0.2%.

PT intervention in ICU is safe.

De Freitas69 Not stated.

APACHE II index.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Any patient in the ICU receiving PT intervention. 146, any patients in the ICU receiving PT intervention. 155, ICU LOS 14 d. Not applicable. Ambulatory status at hospital DC according to presence/absence of joint contractures in ICU, ICU LOS. APACHE II index scores reected severe disease in patients receiving PT. Signicantly more patients with contractures in ICU had a low ambulatory level at hospital DC than those without contractures. ICU LOS signicantly longer in those with contractures. Provided descriptive data for patients in ICU receiving PT. The development of joint contractures in ICU adversely affected ambulatory status at DC from hospital.

Clavet et al70

Prospective, observational study. Prospective, observational study. Retrospective, chart review.

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APACHE 5 Acute Physiologic and Chronic Health Evaluation; IMT 5 inspiratory muscle training; MIP 5 maximal inspiratory pressure; MRC 5 Medical Research Council; NMES 5 neuromuscular electrical stimulation. See Table 1-3 legends for expansion of other abbreviations.

841

842

Table 5Characteristics of Nonclinical Studies


Topic PT for critically ill patients. Summary of Results

Study

Participants, No., Type

Expert opinion Gosselink et al71

10, ERS and ESICM taskforce.

Hanekom et al72

7, Delphi panelists.

Despite a lack of high-level evidence, the following evidence-based targets for PT were identied: deconditioning, muscle weakness, joint stiffness, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. The panelists agreed on a series of statements concerning the indications, technique and dosage of PT Rxs for managing pulmonary dysfunction in intubated patients in ICU. The panelists concluded that an individual mobilization plan must be developed for each patient admitted to an ICU, and made a case that early physical activity and mobilization should be the foundation pillars of PT management in ICU.

Hanekom et al73

7, Delphi panelists.

Clinical management algorithm for the prevention, identication, and management of pulmonary dysfunction in patients in the ICU. Clinical management algorithm for the early mobilization of critically ill patients.

Surveys Hodgin et al74

482, US PTs working with critically ill patients.

Stockley et al75

165, PTs working in UK ICUs.

Current PT practices for patients recovering from critical illness in the US. Current use of passive movements in UK ICUs.

Hayes et al76

165, senior PTs working in Australian or NZ ICUs.

Jones77

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 Current PT practice with respect to VH, barriers to its use, description of its technique in Australia and NZ. ICU directors perception of their PT service. Senior PTs qualications, experience, research, teaching, and job overlap. Exercise prescription by PTs for patients in the ICU in Australia. Prole and role of PTs in European ICUs. Role of PTs in Indian ICUs. Use of tilt tables in the PT management of patients in the ICU in Australia. PT was commonly administered to patients in the ICU during their recovery. 89% required medical referral to initiate PT. The frequency and type of intervention varied based on hospital type and the clinical scenario. 92% routinely treated ventilated, sedated patients in ICUs. Of these, 99% used passive movements routinely and 78% performed passive movements daily. Joints most commonly treated were the shoulder, hip, knee, elbow, and ankle, for a median of 5 times per area, and joints were taken to the end of ROM. 78% monitored the effects of passive movements, with HR and BP most frequently monitored. Only 21% used VH. Lack of training and medical approval were the main barriers to its use. When VH was used, its application varied considerably between respondents. 79% of ICU directors thought the PT service was outstanding or very good. Secretion removal was seen as the PTs main role. 60% believed the PTs work could be covered by other disciplines. 40% of PTs were aware of merging professional boundaries. 94% prescribed exercise routinely for patients in ICU, with active, active-assisted exercises, and mobilization (eg, sit to stand, sit on edge of bed) most commonly prescribed. 34% routinely used outcome measures to monitor exercise prescription, including Spo2, RR, and functional tests. The prole and role of PTs in ICU varied across Europe. 100% reported that PTs were involved in the provision of respiratory therapy, positioning, and mobilization. 55% required medical referral to initiate the provision of PT. 91% were involved in the provision of respiratory therapy and 100% in the provision of mobilization. 67% used tilt tables to assist standing and mobilization. Tilt tables were most frequently used to facilitate weight bearing, prevent muscle contractures, improve lower limb strength, and increase arousal. Title tables most frequently applied to patients with neurologic conditions or prolonged ICU LOS.
(Continued)

Skinner et al78

54 directors and 103 senior PTs in Australian, UK, Canadian, Hong Kong, and South African ICUs. 111, PTs working in Australian ICUs.

Norrenburg and Vincent79

102, PTs working in European ICUs.

Kumar et al80

89, PTs working in Indian ICUs.

Chang et al81

86, senior PTs working in Australian ICUs.

Original Research

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Table 5Continued
Topic Availability of PT services in ICUs and role of PTs and nursing staff in provision of chest PT in Australia. Use of positioning in Australian ICUs. Summary of Results

Study

Participants, No., Type

Chaboyer et al82

71 nurse managers, 6 PTs working in Australian ICUs.

Thomas et al83

71, PTs and nurses working in Australian ICUs.

Dennis et al84 Prevalence of using VH during PT Rxs in Australian ICUs. Professional role and educational preferences of Swedish ICU PTs. Use of passive movements in Australian ICUs.

64, PTs working in Australian ICUs.

Matilainen and Olseni85

57, PTs working in Swedish ICUs.

Wiles and Stiller86

51, PTs working in Australian ICUs.

Stiller and Wiles87 Patient satisfaction with PT service in an ICU. Use of MH by PTs in Australian ICUs.

35, patients in the ICU.

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013 87% had weekday PT cover, 66% had weekend PT cover, , 10% had evening PT cover. Nurses were involved in all aspects of chest PT. PTs were most frequently involved in the provision of mobilization, chest wall vibrations, positioning, percussion, and suction. 86% believed patients should be turned every 2 h. Positions most frequently used on a daily basis were a quarter turn from supine, supine with the head of bed elevated 30, and sitting out of bed. 39% used VH during PT Rxs. VH most frequently used in the setting of sputum retention and respiratory infection. 89% of ICU PTs also worked in other clinical areas. Time spent in ICU ranged from 5-40 h/wk. 100% were involved in the provision of respiratory therapy, mobilization, and limb exercises. 35% routinely assessed passive limb ROM of all patients in the ICU. 14% routinely provided passive limb exercises as a Rx for all patients in the ICU. Prescription of passive limb ROM exercises was variable between respondents. There was a high degree of satisfaction with the personal characteristics of the PTs seen and the PT service provided in ICU. 91% used MH as a Rx technique. 76% used MH as a routine Rx for ventilated patients. There was strong agreement between respondents on the components of MH, preferred Rx positions, contraindications, and perceived benets. There was considerable variation between respondents in the duration, number of breaths, and circuits used when performing MH.

Hodgson et al88

32, PTs working in Australian ICUs.

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ERS 5 European Respiratory Society; ESICM 5 European Society of Intensive Care Medicine; NZ 5 New Zealand; UK 5 United Kingdom; US 5 United Statesct. See Table 1-4 legends for expansion of other abbreviations.

843

identied, the current review included 26 clinical studies on this topic and, while study quality was variable, statistically signicant and clinically important benets resulting from early mobilization were demonstrated. These new clinical studies have shown that early progressive mobilization is feasible and safe, and results in signicant functional benets that may translate into positive effects on the ICU and hospital LOS. Stiller1 noted that the role of physiotherapy in the ICU would continue to be questioned until physiotherapy has been shown to have a favorable impact on broader outcomes of patients in the ICU. The new evidence demonstrating the benecial effects of mobilization on broader outcomes such as the ICU and hospital LOS conrms an unquestionable role for physiotherapy in the ICU. Given that the demand for physiotherapy services often outstrips the resources available, and the new evidence demonstrating the effectiveness of physiotherapy interventions aimed at early mobilization, ICU physiotherapists should give priority to interventions aimed at early progressive mobilization. To be successful, implementation of early progressive mobilization relies on an ICU culture that considers mobilization an essential part of multidisciplinary care. Safety guidelines and protocols for progressive mobilization of patients in the ICU are available.34,37,42,47,89 Eighteen new clinical trials were identied that evaluated the effectiveness of multimodality respiratory physiotherapy for adult, intubated, mechanically ventilated patients in the ICU. The results of these trials support and extend the conclusions made by Stiller in 2000,1 namely, that multimodality respiratory physiotherapy may result in short-term improvements in pulmonary function. While there is some new evidence from RCTs that the provision of routine multimodality respiratory physiotherapy can impact positively on outcomes such as duration of intubation and the ICU LOS, there is, however, a similar amount of new high-quality evidence suggesting that it may not. In terms of specic respiratory physiotherapy interventions, there is limited evidence from new randomized crossover trials suggesting that expiratory rib-cage compression is ineffective and that MH may have benecial short-term effects on respiratory compliance, concurring with the conclusions made in the 2000 review.1 New evidence has emerged demonstrating that VH is as effective as MH. There is new high-quality evidence concerning the effectiveness of IMT for patients in the ICU; however, this evidence is scarce, hence the routine or selective use of IMT for patients in the ICU cannot be recommended at present. Similarly, the evidence that has been published since 1999 concerning the effectiveness of NMES is limited and, thus, clinical recommendations regarding its use in ICU cannot be made.
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Limitations of this systematic review included the variable methodological quality of the studies. The diverse range of study samples and study methodology precluded pooling of results and statistical analysis. The interventions that were provided usually comprised numerous components, making it impossible to determine the effectiveness of individual treatment components. A strength of this literature review was the inclusion of all clinical studies that have evaluated physiotherapy for adult patients in the ICU, irrespective of study design. Additionally, by reviewing the evidence concerning a broad range of physiotherapy practice, rather than focusing on one specic type of intervention (eg, multimodality respiratory physiotherapy or mobilization alone), it has been possible to highlight the emerging evidence concerning the benecial effects of early progressive mobilization compared with other physiotherapy interventions. Conclusions In summary, the evidence concerning the efcacy of routine multimodality respiratory physiotherapy for adult, intubated patients receiving mechanical ventilation remains unclear. There is strong, albeit limited, evidence published since the review in 2000 showing that physiotherapy intervention focusing on early progressive mobilization is feasible and safe, and results in signicant functional benets, which may translate into a reduced ICU and hospital LOS. This emerging evidence conrms the role of the physiotherapist in ICU and highlights that early progressive mobilization is an effective area of physiotherapy clinical practice for adult, intubated, mechanically ventilated patients. Further research to conrm the efcacy of early progressive mobilization is required, in particular to determine the optimal dosage in terms of its most effective components, intensity, duration, and frequency. Acknowledgments
Author contributions: Dr Stiller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Stiller: contributed to the literature search, identication of relevant studies, data extraction, analysis of the results, and writing of the paper. Financial/nonnancial disclosures: The author has reported to CHEST that no potential conicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: The author would like to thank Alisia Jedrzejczak, BPhysio (Hons), and Kate Roberts, BAppSc (Physio), BSc, for their helpful comments regarding this paper.

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